COVID-19 Associated Reversible Cerebral Vasoconstriction Syndrome Successfully Treated with Nimodipine and Aspirin.

There have been limited cases linking SARS-CoV-2 infection with the development of reversible cerebral vasoconstriction syndrome (RCVS). We hereby report a rare case of RCVS in the setting of mild SARS-CoV-2 respiratory infection successfully treated with nimodipine and aspirin. SARS-CoV-2 attacks the ACE2-receptors, which are expressed in various body organs including the lungs, kidneys, and blood vessels. Vasoconstriction can result from down-regulation of the ACE2-receptors that can lead to sympathetic hypertonia of the cerebral blood vessel walls and/or over-activation of the renin-angiotensin axis.

Unruptured aneurysmal clipping complicated by delayed and refractory vasospasm: case report.

BACKGROUND: Delayed symptomatic vasospasm is a rare complication following clipping of an unruptured intracranial saccular aneurysm. There have been ten reported cases of delayed symptomatic vasospasm and only two of these occurred after 2 weeks from initial intervention. Our case is the first to document the refractory nature of such vasospasm despite aggressive first line therapy. CASE PRESENTATION: Here, we present a 67-year-old female who had surgical clipping of a 10x7mm right middle cerebral artery (MCA) bifurcation aneurysm. Her surgery and initial postoperative course were uncomplicated, but she presented with acute left hemiparesis, dysarthria, headache and vomiting on post-op day 29 secondary to vasospasm of M2. She was initially stabilized with intra-arterial verapamil then managed with volume expansion, permissive hypertension, and nimodipine. She developed recurrent vasospasm of M2 the following day and was again treated with intra-arterial verapamil. Magnetic resonance imaging (MRI) brain showed an infarction involving the right basal ganglia, frontal lobe, and parietal lobe and her hospital course was complicated by super-refractory status epilepticus. At her follow up appointment she displayed continued left lower extremity weakness, left visual field defect, and left-sided neglect. CONCLUSIONS: Overall, cerebral vasospasms associated with unruptured aneurysms remain rare complications and are not often monitored for after initial recovery. Reviewing the documented cases highlights the unpredictability of when these events occur with our current knowledge. Current hypotheses for the mechanisms responsible for delayed and refractory vasospasms include: blood-derived breakdown products, mechanically induced vasospastic responses, and delayed reactions from the trigemino-cerebrovascular system (TCVS). The uncertainly of these events warrants further research and supports a strong argument for monitoring patients with initial surgical clipping up to a month out from their initial procedure.

Functional Outcomes of Intravenous Thrombolysis in Octogenarians and Nonagenarians Through Telestroke: Single-Center Experience.

Background: Patients aged ≥80 years are often underrepresented in stroke trials. Observational studies have shown that older patients have worse outcomes compared with younger patients, but outcomes in patients aged ≥80 years treated with intravenous (IV)-alteplase specifically through telestroke (TS) have not been studied. Aim: To compare clinical and safety outcomes in stroke patients aged ≥80 and 60-79 years treated with IV-alteplase via TS. Methods: The Medical University of South Carolina TS database was analyzed to identify IV-alteplase-treated patients aged 60-79 and ≥80 years between January 2015 and March 2018. Baseline demographics and TS-specific variables were compared. Clinical outcomes were assessed using the 90-day modified Rankin Scale (mRS). Safety outcomes were evaluated by comparing symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis was performed to determine odds ratio (OR) for good outcome (mRS 0-2) in the older age group at 90 days. Results: IV-alteplase was used in 151 patients in ≥80 years age group and 273 patients in 60-79 years age group. The older age group had more women and a higher National Institutes of Health Stroke Scale. The mean "ED-door-to-TS-consultant-login" time was shorter (21.6 min vs. 25.6 min; p = 0.048), but "TS-consultant-login-to-alteplase" time was longer (22.1 min vs. 19.3 min; p = 0.01) in the older age group. No difference was noted in eventual "door-to-needle" time. The older age group had fewer good outcomes (39.1% vs. 74%; p = 0.001) and more deaths (38% vs. 14%; p = 0.001) at 90 days. The sICH rates were similar in the two groups. The OR for good outcome in ≥80 years age group was 0.20 (95% CI: 0.12-0.34) after controlling for baseline variables. Conclusions: Stroke patients aged ≥80 years treated via TS have similar post-thrombolysis hemorrhage rates but worse clinical outcomes compared with patients aged 60-79 years.

Stroke Care Trends During COVID-19 Pandemic in Zanjan Province, Iran. From the CASCADE Initiative: Statistical Analysis Plan and Preliminary Results.

BACKGROUND: The emergence of the COVID-19 pandemic has significantly impacted global healthcare systems and this may affect stroke care and outcomes. This study examines the changes in stroke epidemiology and care during the COVID-19 pandemic in Zanjan Province, Iran. METHODS: This study is part of the CASCADE international initiative. From February 18, 2019, to July 18, 2020, we followed ischemic and hemorrhagic stroke hospitalization rates and outcomes in Valiasr Hospital, Zanjan, Iran. We used a Bayesian hierarchical model and an interrupted time series analysis (ITS) to identify changes in stroke hospitalization rate, baseline stroke severity [measured by the National Institutes of Health Stroke Scale (NIHSS)], disability [measured by the modified Rankin Scale (mRS)], presentation time (last seen normal to hospital presentation), thrombolytic therapy rate, median door-to-needle time, length of hospital stay, and in-hospital mortality. We compared in-hospital mortality between study periods using Cox-regression model. RESULTS: During the study period, 1,026 stroke patients were hospitalized. Stroke hospitalization rates per 100,000 population decreased from 68.09 before the pandemic to 44.50 during the pandemic, with a significant decline in both Bayesian [Beta: -1.034; Standard Error (SE): 0.22, 95% CrI: -1.48, -0.59] and ITS analysis (estimate: -1.03, SE = 0.24, p < 0.0001). Furthermore, we observed lower admission rates for patients with mild (NIHSS < 5) ischemic stroke (p < 0.0001). Although, the presentation time and door-to-needle time did not change during the pandemic, a lower proportion of patients received thrombolysis (-10.1%; p = 0.004). We did not see significant changes in admission rate to the stroke unit and in-hospital mortality rate; however, disability at discharge increased (p < 0.0001). CONCLUSION: In Zanjan, Iran, the COVID-19 pandemic has significantly impacted stroke outcomes and altered the delivery of stroke care. Observed lower admission rates for milder stroke may possibly be due to fear of exposure related to COVID-19. The decrease in patients treated with thrombolysis and the increased disability at discharge may indicate changes in the delivery of stroke care and increased pressure on existing stroke acute and subacute services. The results of this research will contribute to a similar analysis of the larger CASCADE dataset in order to confirm findings at a global scale and improve measures to ensure the best quality of care for stroke patients during the COVID-19 pandemic.

Impact of Treatment Time on the Long-Term Outcome of Stroke Patients Treated With Mechanical Thrombectomy.

OBJECTIVE: To assess the long-term functional outcome of stroke in patients treated with mechanical thrombectomy (MT) performed during work hours (on-hours) versus after-hours, weekends, and official holidays (off-hours). METHODS: Data on all patients receiving MT at a comprehensive stroke center was collected between December 2014-December 2016. Our primary outcomes were the discharge and 90-day modified Rankin Scale (mRS). We developed propensity scores for off-hours treatment and used inverse probability of treatment weights to address confounding. We estimated logistic regression to assess the relationship between off-hours treatment and favorable patient outcomes. Independent variables include receiving thrombectomy during the off-hours, admission National Institute of Health Stroke Scale (NIHSS), door to groin time in minutes, age, and race. RESULTS: During the study period, 80 (41%) patients underwent thrombectomy during on-hours and 116 (59%) during off-hours. Mean age was 69.1 years for the on-hours group and 64.1 years for the off-hours group (P = .02). There were no statistically significant differences in median admission NIHSS, rate of alteplase administration, mean time from last known well to thrombectomy, rate of revascularization, and rate of hemorrhagic transformation between the 2 groups. Logistic regression analysis showed the probability of a favorable outcome at discharge (mRS ≤ 2) is 12.6 % lower for off-hours patients (P = .038, [95%CI -.25 to -.01]). For patients with a 90-day mRS (n = 117), the probability of a favorable outcome was 18.7% lower for those treated during the off-hours (P = .029, [95%CI -.36 to -.02]). CONCLUSIONS: There is a higher probability of a good functional outcome in acute ischemic stroke patients who receive MT when performed during regular work hours.

In Search of the Optimal Antithrombotic Regimen for Intracerebral Hemorrhage Survivors with Atrial Fibrillation.

Spontaneous intracerebral hemorrhage (ICH) constitutes 10-15% of all strokes, and is a significant cause of mortality and morbidity. Survivors of ICH, especially those with atrial fibrillation (AF), are at risk for both recurrent hemorrhagic and ischemic cerebrovascular events. A conundrum in the field of vascular neurology, neurosurgery, and cardiology has been the decision to initiate or resume versus withhold anticoagulation in survivors of ICH with AF. To initiate anticoagulation would decrease the risk of ischemic stroke but may increase the risk of hemorrhage. To withhold anticoagulation maintains a lower risk of hemorrhage but does not decrease the risk of ischemic stroke. In this narrative review, we discuss the evidence for and against the use of antithrombotics in ICH survivors with AF, focusing on recently completed and ongoing clinical trials.

A contemporary and comprehensive analysis of the costs of stroke in the United States.

BACKGROUND: While several studies have determined direct costs associated with stroke there is a paucity of research involving indirect costs, especially in younger patients. AIM: Perform a cost of illness analysis for ischemic and non-traumatic hemorrhagic stroke in the US involving both direct and indirect costs in all age groups. METHODS: Nationally representative data was obtained from the Medical Expenditure Panel Survey (2003-2014). Subjects were dichotomized based on reported history of stroke. Two-part econometric models were used to estimate the adjusted incremental direct expenditure for patients with stroke. We used generalized linear model with family gamma, log link for the adjusted analysis of annual wage, a negative binomial regression model for the adjusted analysis of missed-work day, and a logistic regression model to estimate the probability of full-year employment. Loss of productivity due to premature death was computed using Present-Value of one life and annual number of deaths from 2014 National Vital Statistics. All costs are represented in 2016 US-dollar values. RESULTS: Out of 253,235,052 participants, 8,101,159 (3.2%) reported history of stroke. Weighted samples of 10,155 stroke participants and 314,694 control group were compared. Adjusted annual direct costs for each stroke participant was $4317 (95% CI: $3828-$4807) greater than control resulting in a net $38 billion incremental expenditure. Based on salary difference, missed workdays, and mortality, indirect cost from under-employment was $38.1 billion and from premature mortality was $30.4 billion. CONCLUSION: Total aggregate of $103.5 billion expenditure was incurred with 66% being from indirect costs based on 2016 US-dollar values.

Pseudobulbar affect after stroke: a narrative review.

BACKGROUND: Pseudobulbar affect (PBA) is a neuropsychological condition of emotional lability and affective dysregulation associated with a variety of neurological conditions such as stroke, traumatic brain disease, and neurodegenerative disease. The true prevalence and medico-social burden of PBA associated with stroke is unclear. Often confused with post-stroke mood disorders, PBA is under-recognized and under-treated. OBJECTIVE: To provide a comprehensive narrative synthesis of published literature on the topic of PBA. METHODS: Literature review was performed by searching the key words "pseudobulbar atrophy", "emotional incontinence," and "stroke" in PubMed. Only manuscripts published in English were appraised and relevant content was extracted, synthesized, and summarized. RESULTS: A narrative overview was performed on the following topics: epidemiology, pathophysiology, clinical features of differential diagnosis, impact on public health, and therapeutic options. CONCLUSION: PBA remains an under-treated condition with significant psychosocial burden on both effected stroke survivors and their families. Advances have been made in developing consensus-based clinical diagnostic criteria for PBA. Early identification and prompt initiation of therapeutic measures are required in these stroke patients. Further research is needed to develop better PBA diagnostic criteria and more cost-effective therapeutic treatment options.

Antiplatelet Agents in Secondary Stroke Prevention: Selection, Timing, and Dose.

PURPOSE OF REVIEW: This narrative review critically evaluated the published studies regarding the systematic use of antiplatelet agents for secondary stroke prevention. RECENT FINDINGS: Stroke is a leading cause of morbidity and mortality around the world. Multimodal prevention is the most viable strategy for reducing the societal burden of stroke recurrence. For secondary stroke prevention, antiplatelet therapy is at the core of effective long-term vascular risk reduction among survivors of an ischemic stroke or transient ischemic attack (TIA). In addition to aspirin, there are several antiplatelet agents proven to be efficacious in averting recurrent vascular events after an index ischemic stroke or TIA. However, beyond the challenges of keeping up with recent advances in antiplatelet drug options for secondary stroke prevention, questions linger about the most appropriate selection, timing, and dosing of antiplatelet treatment for a given patient. We narratively summarized the pharmacological properties of key antiplatelet drugs; discussed the evidence regarding efficacy, selection, timing, and dosing of various antiplatelet treatment regimens; and highlighted ongoing clinical trials identifying novel therapies with more favorable risk-benefit profiles than currently available antiplatelet agents for patients with a recent history of ischemic or TIA stroke. Finally, we reviewed published data on antiplatelet therapies that could potentially be applied in the management of commonly encountered challenging clinical scenarios.

Levodopa Responsive Parkinsonism in Patients with Hemochromatosis: Case Presentation and Literature Review.

Hemochromatosis is an autosomal recessive disorder which leads to abnormal iron deposition in the parenchyma of multiple organs causing tissue damage. Accumulation of iron in the brain has been postulated to be associated with several neurodegenerative diseases including Parkinson's disease. The excess iron promotes Parkin and α-synuclein aggregation in the neurons. Excess iron has also been noted in substantia nigra on MRI especially using susceptibility weighted imaging in patients with Parkinson's disease. We present a case of a young male with alleles for both C282Y and H63D who presented with signs of Parkinsonism and demonstrated significant improvement with levodopa treatment.